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TERESA THOMPSON, CPC, CMSCS, CCCTM CONSULTING, INC.
P O BOX 267CARLSBORG, WA 98324
E & M Chart Auditfor the
Allergy Practice
Auditing – Why and What
Physician documentationPatient account postingsCredit BalancesAccounts Receivables – outstanding balances greater
than 90 days
Physician Documentation Verification that the coding is appropriate to the
documentation Education and training if inappropriate coding Refunding third party payers if payments have been received
ALLERGIST CODING CURVE4
National National99201 .47 % 99241 .52 %99202 5.00 % 99242 3.48 % 99203 30.15% 99243 30.42% 99204 51.32% 99244 54.02% 99205 13.06% 99245 11.56%
4
ALLERGIST CODING CURVE5
National99211 3.98 % 99212 6.77%99213 55.25% 99214 31.09%99215 2.91 %
5
Components of Evaluation and Management Codes
Components of the E & M
HistoryExamMedical Decision MakingTime is ONLY important when more than 50% of the
encounter is counseling and coordination of care
Requirement for New/Consult Patientvs. Established Patient
History, Exam & Medical Decision Making need to be at the same level or higher to support the level of care.
Two of the three of the components at the same level or higher to support the level of care.
The history and exam must be appropriate to the patient’s presenting problem
CONSULT-HOSPITAL 99251 99252 99253 99254 99255
CONSULT-3 of 3 99241 99242 99243 99244 99245
NEW PT- 3 of 3 99201 99202 99203 99204 99205
HISTORY
CHIEF COMPLAINT Required Required Required Required Required
HX of PRESENT ILL Brief(1-3) Brief(1-3) Extended(4+) Extended(4+) Extended(4+
REVIEW OF Problem Extended Complete Complete
SYSTEMS Pertinent (1) (2-9 System) (10 + system) (10+ system)
PAST HX Pertinent-1 Complete-1ea Complete-1ea
FAMILY HX Pertinent-1 Complete-1ea Complete-1ea
SOCIAL HX Pertinent-1 Complete-1ea Complete-1ea
Perform/ Perform/ Perform/ Perform/ Perform
EXAM document document document document document
1 organ 2-4 5-7 8 organ 8 organ
system organs Organ systems systems systems
MED. DEC MAKING (2 of the 3 must be met or exceeded)
MGMT OPT. & DX. Minimal (1) Minimal (1) Limited (2) Multiple (3) Extensive(4)
AMT DATA &COMPLEX Minimal(1) Minimal (1) Limited (2) Moderate (3) Extensive(4)
RISK OF COMPLICAT. Minimal Minimal Low Moderate High
ESTABLISH PT
2 OF 3 99211 99212 99213 99214 99215
HISTORY
CHIEF COMPLAINT Required Required Required Required Required
HX PRESENT ILL. Brief Brief Extended Extended
SYSTEM REVIEW Prob. Pertinent Extended Complete
PAST HISTORY Pertinent-1 Complete:
FAMILY HISTORY Pertinent-1 Choice of 2
SOCIAL HISTORY Pertinent-1 ele PFS Hx.
Perform/ Perform/ Perform/ Perform/
EXAM document document document document
1 organ 2-4 organ sys 5-7 organ system 8 organ systems
MED. DEC MAKING
MGMT/OPTION DX Minimal (1) Limited (2) Multiple (3) Extensive(4)
AMT DATA/COMPLEX Minimal(1) Limited(2) Moderate(3) Extensive(4)
RISK OF COMPLICAT. Minimal Low Moderate High
HISTORY AUDIT SHEET
HPI: Chief Complaint –Reason for encounter Location – specific to area of the body Quality – describe the pain – dull sharp; wound
jagged, dirty or clean Severity – measure on a scale Duration- how long, since when, etc Context- how complaint occurred Modifying factor- what has alleviated symptoms Signs and Symptoms – additional information from patient
HISTORY AUDIT SHEET
Review of Systems: Ten are required for a complete ROS Pertinent positives and negatives must be
documented A notation of negative for the remaining review
of systems may be documented for the remaining systems
Can be documented by staff patient Must be reviewed by physician Can be separate or part of the HPI Cannot use one statement in both categories
History Audit Sheet
Past, Family and Social History: Past – Events in the patient’s past
medical/surgery history Family – Diseases that impact patient’s health Social - Factors which are age appropriate that impact from an
environmental and social pattern
Exam Audit Sheet
The 1995 guidelines or the 1997 guidelines can be used for documentation
Allergy has a specific exam for the specialtyAbnormal findings must be describedNormal findings can be indicated by negative
1995 Exam Components
Problem Focused: One organ systemExpanded Problem Focused: Two or more organ
systems (2-4)Detailed: Two or more with detailed information
(5-7)Comprehensive: Eight or more organ systems
MEDICAL DECISION MAKING
Number of Diagnosis and Treatment OptionsAmount of Data and Complexity of DataRisk
Number of Diagnosis & Treatment Options
New ProblemEstablished problem stableEstablished problem worseningEstablished problem, improvedWorkup plannedNo workup planned
Amount & Complexity of Data
Review/order lab testsReview/order routine x-raysReview/order medicine testsDiscussion of tests results with performing
physicianDecision to obtain old records & documentDirect visualization & independent interpretation
documented
Risk
Presenting ProblemDiagnostic ProcedureManagement Options
Presenting Problem
Minimal: One self limited or minor problem
Low: Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated illness/injury
Presenting problem con’t
Moderate: One or more chronic illness with mild exacerbation Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis Acute illness with systemic symptoms Acute complicated injury
Presenting Problem con’t
High: Chronic illness with severe exacerbation Acute or chronic illness/injury that may pose a threat to life or
bodily function
Diagnostic Procedures Ordered
Minimal: Lab tests requiring veni-puncture X-rays Ultrasounds
Low: Superficial need biopsies Skin biopsies Pulmonary function tests
Diagnostic Procedures con’t
Moderate: Diagnostic endoscopy Deep needle or incisional biopsy
High:Diagnostic endoscopy with risk factors
Management options
Minimal: Rest Gargles Elastic/superficial dressings
Low: Over the counter drugs – saline washes Minor surgery – ear piercing Physical Therapy
Management Options con’t
Moderate: Minor surgery with risk Elective major surgery Prescription drug management Closed treatment of fracture w/o manipulation
Management Options con’t
High: Elective major surgery with risk Emergency major surgery Decision not to resuscitate or de-escalate care because of poor
prognosis Drug therapy requiring intensive monitoring for toxicity. High morbidity mortality without treatment
What about Time?
Time is only used if more than 50% of the encounter is counseling and co-ordination of care. You must document:
1. Total face to face time2. The amount which was counseling3. The counseling and coordination of care
discussion
Case #1 - History
CC: Rash.Pt has experienced symptoms since 6 months of age. She has had frequent rashes, on her trunk and extremities. Her skin gets dry with red patches. Rash is perennial, no seasonal changes so far. She has had distatin and topical Benadryl.
Case # 1 - History
Past history – birth wt 6lbs neotal jaundiceMedication allergies: NKDAFamily hx: Hay fever, migraine –motherROS: Constipation and bloating. All remaining 14
systems are negative
Case #1 - Exam
Gen: ht 35 1/2 “, Wt- 24#, Pulse 118, RR 24 WN – thin
Skin – normal Nose - normalHead – normal Mouth - normalEyes – normal Neck - normalEars – normal Resp - normalEars – normal Heart – normalExtrem – normal Neuro - normal
Case #1 – A/P
Lab data – negative CBC & IG. Prick testing for peanut, egg, cows milk, wheat, walnut, fish soy shrimp, corn, are negative. Inhalants are negative for trees and grasses.
Case #1 A-P
Chronic atopic dermatitis, in remission todayRole for IgE-mediated food allergy appears unlikely,
food intolerance remains possibleRec: Daily hydration followed by Cerave Cream.
Limited use of hydrocortisone cream. No dietary restrictions for now. Be observation for signs of food intolerances
Case #2
CC: watery eyes, nasal congestion- chronic. Pt has had increasing rhinoconjunctivitis symptoms over the past year. She was tested for allergy when she was living in another state many years ago and found to be allergic to dust mite and animal dander. She is concerned about allergies as a trigger for her symptoms. She also has a history of asthma.
Case #2
Past medical history - - negativeFamily history – Brothers have hay fever and asthmaSocial history – not a smoker, enjoys outdoor
activities and has a dog for a petROS – GI, Endocrine, Resp are positive the
remaining 14 systems are negative
Case #2Gen – BP 118/70, Ht 5’10”, Wt 150, Pulse 82, RR 12,
healthy in NADSkin – normal Head – normalEyes – normal Ears – NormalNose – pale boggy mucosa, edema of turbinates,
discharge watery clear, no polypsMouth – normal Neck – normalResp – normal Heart – normalAbd – normal Extrem – normal, Neuro Normal
A/P
Seasonal and perennial allergic rhinoconjunctivitis that has worsened over the past year
Mild persistent asthma with allergic triggerRec: Nasal irrigationsEnvironmental controlsDecongestants with antihistamineNasal spray, RX for eyedrops, allergy
immunotherapy recommended, Rx for asthma
Case #3
CC: evaluation of allergies – R/O VCD vs asthma, cough - review meds. Cough is worse at night but not waking up. Vomiting , thick mucus associated with cough. Headache over the past 3-4 days. Sinus pressure for three days also.
No change in environmental hx, ROS not updated.
Case #3
Exam: General – normal skin – normalSinus tender both left and rightEyes – normal Lungs - normalEars – normal Heart - NormalNose – septum normal, mucus watery and clear with
edemaOropharynx – normal Neck - normal
Case #3
A/PDx: Seasonal, perennial allergic rhinitis which is
worse; Asthma which is not well controlled – cough, PND
RX – Trial of bronchodilator, consider CT if cough persist, check for gerd
